Madhya Pradesh Technical Assistance and Support Team (MPTAST) under the Health Sector Reforms Program (MPHSRP)

March 2015

Submitted to: Department for International Development, UK

Submitted by: Madhya Pradesh Technical Assistance and Support Team (MPTAST) FHI 360 H-5, GROUND FLOOR, GREEN PARK EXTENSION NEW DELHI 110 016 TEL: 91-11-4048- 7777 www.fhi360.org Introduction

Moving ahead in the direction of universal health coverage, the Dept. of Public Health and Family Welfare of the Government of Madhya Pradesh has taken various initiatives. With a plethora of service additions, widespread public welfare schemes and better monitoring systems, a new platform for health service delivery was launched in the year 2013. The platform aimed at decentralization of basic health services up to village level and utilized the existing platform of Anganwadi Centers and resource pool of ASHAs which already existing in villages providing nutrition and health services separately. The innovation brought in a much sought after convergence of the department of ICDS , Health and Panchayti Raj and foundation for development of village level health units called Gram Arogya Kendra (GAK) was laid down. The Gram Arogya Kendra were established at the existing anganwadi centres and ASHAs were trained to the new role envisaged for them.

Service Provision at GAK

Services provided by ANM: Conducting VHND, Providing ANC & PNC services during VHNDS, Conducting 5 provisioned tests (Hemoglobin, Urine Pregnancy test, Malaria test by RD kit, Urine albumin and Sugar test) in cases where needed and Immunization.

Services Provided by ASHA:   Dispensing medicines for minor ailments and seasonal diseases   Maintaining village health register- Details of village health problems, target  couples, pregnant mother, high risk mothers, births, deaths etc. 

  Meeting of adolescent girls & health counselling   Meetings of Village health & sanitation committee / Gram Sabha Swasth Gram Tadarth Samiti. 

Support provided by MPTAST to the state The Anganwadi cum Gram Arogya Kendra at Kankarkheda village, district. In order to help the state in smooth functioning of these village level units, MPTAST provided support in assessment and gap filling at these centers in terms of delivery of services by catalyzing availability of human resources, hands on training to ASHA and ANM, mobilizing supplies- drugs and consumables and stimulating VHSNCs to oversee the functioning of the GAKs.

To strengthen the Gram Arogya Kendra in a structured way which can be presented as a model for the state, 2 blocks in each of the 16 TAST supported districts were identified, list which is followed in the table below:

2 List of Blocks and number of GAKs- MPTAST SN Districts of Blocks 1 GAKs Block 2 GAKs MPTAST

1 Sehore Icchawar 131 Shyampur 244 2 Sondhwa 133 Ambuwa 86 3 Gandhwani 144 164 4 Kalyanpura 126 Thandla 111 5 Rajpur 85 Pati 110 6 Shahpura 209 Patan 165 7 Mohgaon 87 Beeja Dandi 132 8 Dindori Samnapur 114 Dindori 191 9 Rewa Sirmour 242 Raipur 236 10 Sidhi Majholi 129 Rampur 190 11 Satna Amarpatan 169 Majhgawan 296 12 Sagar Kesli 162 185 13 Badamalhera 152 Raj Nagar 120 14 Niwari 123 170 15 Tedukheda 132 Damoh 237 16 Panna 249 Gunnor 120 TOTAL 2387 2757 GRAND TOTAL 5144

3 Methodology

To improve the organization of services and service delivery at Gram Arogya Kendras, the district team members were oriented on the kind of support to be provided to the districts. For the purpose of structuring the efforts being given by district teams, a structured tool was adopted. This was developed by the state ASHA cell, and has enlisted the essential requirements at the GAKs (Please refer to the checklist annexed with this document). After district teams were oriented on checklist, the following protocol was developed for supportive supervision.

1. Prior information to district authorities before visiting any GAK 2. Prior telephonic consultation with the ASHA/ ANM of the area 3. A government official i.e. SMO/Sector supervisor/ANM/MPW to accompany the TAST team member during the visit 4. To carry few of the critical logistic items with the visiting team in case it is in shortage at the GAK and can be replenished hands on. 5. To visit GAK preferably on a Village Health and Nutrition Day (VHND). 6. To carry a functionality assessment of the center on the basis of checklist. 7. To provide hands on solutions, recommendations, hands on training for service delivery to the GAK workers- ASHA and ANM is available on site 8. To fill the checklist hard copy at the end of the visit and mention ‘action taken’ based on the support provided for each item in the checklist. 9. To inform the assessment findings, support provided and support needed further to the district officials 10. To follow-up of further the progress with the district & block officials

4 Monitoring of the GAK strengthening activities

1. For the monitoring of the GAKs in all 50 districts, state was supported with development of web based monitoring system. This is in form of a website called “community action or ASHA” website. The website was developed and is maintained by MPTAST consultant at the state ASHA cell. The website has a block level entry system for the GAK assessment based on the checklist. The data can be compiled for each block, district and for whole state and various analytics can be developed through it to see the development happening at GAKs at various levels. It can generate periodic data for GAK functionality status. The readily available reports can be seen for progress of any GAK based on the checklist parameters. It can further categorize GAKs into A, B, C & D categories for any given district, block or for the whole of Madhya Pradesh.

The link for ASHA website: http://mpsdc.gov.in/mpasha/

Snapshot of ASHA Website

2. For the monitoring of assessment and improvements done by the district TAST team members, a data entry tool was developed. This was an excel sheet based tool and provided live data entry option to the district teams and has an automated compilation system at the district and state level.

5 Results

The structured support provided by TAST to the GAKs using checklist based assessment and improvement was started from April 2014. During the initial months, all district team members including TO health, TO WASH, TO Nutrition and DPCs used the checklist for this exercise and helped their respective districts in identified blocks to improve the functionality of the GAKs. Eventually, the exercise has been conducted by the TO health in their respective districts. Starting from April 2014, till the end of March 2015, a total of 1020 GAKs have been assessed and have been provided with hands on support for improvement in its service delivery. The number, however, varies from district to district.

The grading of the functional status of the GAKs based on the checklist scores was done into three categories. At the start of the exercise, during the month of April, 2014, a total of 112 GAKs were visited and their categorization based on the checklist was done. Which showed only 19% to be in category C, 28% in category B and 53% in category C. After the continuous efforts of the district teams, institutionalization of regular supportive supervision mechanism in districts and repeated guidance from the district authorities the situation looks much improved now. Till the end of March out of a total of 1020 GAKs supported, only 15% fall in category C, 56% in category B and 29% are in category A.

Categories of 669 GAKs based on the checklist scores (April -September 2014)

District wise status & categories:

GAK supported Category A Category B Category C

District

(April-Sep 2014)

Alirajpur 48 16 29 3 Badhwani 28 5 19 4

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Chhatarpur 130 11 86 33 Dhar 64 51 13 0 Dindori 74 6 62 6 Damoh 37 17 20 0 Jabalpur 43 5 30 8 Jhabua 68 9 51 8 Mandla 59 8 37 14 Panna 33 10 20 3 Rewa 84 12 60 12 Sagar 25 11 9 5 Satna 30 1 12 17 Sehore 148 87 50 11 Sidhi 80 34 36 10 Tikamgarh 69 17 36 16 Total 1020 300 570 150

Status of parameters on assessment checklist: The assessment checklist for the GAKs has a total of 57 parameters and these parameters are sub grouped into four areas. The first section is of infrastructure and basic amenities (13 parameters),

the second is availability of instruments and furniture (24 parameters), the third is about availability of medicines and consumables (13 parameters) and last section contains the details of informations available & displayed at GAKs (7 parameters).

Each of the Gram Arogya was visited at least once for assessment on the checklist parameters and follow up was done by indirect methods like telephonic confirmation from the ASHA or

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ANM or the block community mobilizer visiting the village afterwards. Further, few of the GAKs were randomly visited by district/ state teams to understand and validate the quality of data received. The checklist scores for various parameters were compared for the scored by deducting the “actions taken” from the final checklist scores for each parameter.

The comparative status showing the improvement in parameters, four all four sections are mentioned in the graphs below. The improvement brought about by TAST efforts is prominently visible for most of the checklist items and can be largely attributed to mobilization of basic furniture, instrument, drugs and consumables.

Few of the common issues identified and the action taken to resolve them in the districts are summarized below along with the graphs depicting the improvement.

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Other support provided to State

A. Modification of parameters in the checklist: The GAK assessment checklist developed by the state had few parameters which were no longer applicable at the GAK level. Also a few were redundant and were not suitable for the assessment. The state ASHA cell was informed about them and subsequently it were removed. Availability of Sprit lamp, availability of village health plan, availability of mothering tablets are few examples which were eventually removed from the checklist. B. Modification in the website: The state cell was also provided with consultation to further modify the ASHA website to add few analytical options into it. For example, it was not capable of comparative analysis of the GAKs for two time periods. This feature was added to track the progress of GAKs in any district or block with respect time.

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Commonest Issues and Actions Taken/ Recommended at district level

District – Alirajpur Issues Action Taken 1. List of temporary methods of family 1. Urged BPM to avail village map at all planning is not available. VHND sites. 2. Facilitated ANM ASHA AWC to write 2. Functional BP instrument is not available. Contact Information of the District and Block official at vantage point of GAK 3. Village health register is not updated. 3. Instructed ANM to write the desired information by utilizing given Untied

funds for VHSC 4. Instruct ANM how to update Village health register. District- Chhatarpur 1. Basic information about the village is 1. Sector supervisor to help ASHA to prepare available with the ASHA but not updated. village health plan in consultation with 2. Village health plan is not prepared. VHSC members. 3. Contact information of DC, CMHO, 2. SMO to make available the village map DPM, BMO, CDPO, Janani express etc is at all VHND sites. not written. 3. ASHA will ensure the same on wall the 4. Information about married & target Information about married & target couples, pregnant women, Newborns, couples, pregnant women, Newborns, under five children, malnourished under five children, malnourished children children, children registered in AWC is and children registered in AWC. not updated. 4. SMO/BCM /MPW will be ensuring that 5. All vaccines with diluents is available all basic medicine should be available at only at Vaccination day. GAK.

District Dhar 1. Basic information about the village is 1. BCM to ensure the availability of available with the ASHA but not updated. basic information about the village. 2. Details of Self Help Group, Mothers Help 2. BCM has to assured the availability of Committee is not available. Health Plan within a month.

3. Register for other activities not being done at the Gram Arogya Kendra. District Damoh 1. Details of mid-day meal scheme group are 1. Informed to ASHA Sahyogi and BCM not made from last 3 months. regarding lack of Contact details. 2. Contact information of DC, CMHO, 2. Training given to make list of DPM, BMO, CDPO, Janani express etc is targeted couple. not available. District Dindori 1. The VHC has details of the information about the funds received from health department, women & child development

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department and its expenditure but not in GRKs. 2. Details of Self Help Group, Mothers Help

Committee available but not displayed. District Jabalpur 1. Contact information of DC, CMHO, 1. Supervisor has promised to complete basic DPM, BMO, CDPO, Janani express etc is information about the village within a incomplete. week.

2. List of temporary methods of family planning is not in GAKs. 3. IFA tablets - small tablets is not available. District Jhabua 1. Contact information of DC, CMHO, 1. Instruction is given to make village map. DPM, BMO, CDPO, Janani express etc is 2. Instruction is given about health not updated. services provided by ANM & MPW. 2. Details and lists of immunization, TB, 3. BCM will conduct meeting with ANM and Leprosy, Diarrhoea, Malaria patients are ASHA to discuss the issues regarding not available. GAKs 3. Names and services provided by ASHA, 4. Identified issue discussed with BCM and AWW and Sahayika are not displayed. advised BCM to ensure that gaps and fulfilled it.

5. Made ASHA understood what health plan is and which all activities are come under this plan. District Mandla 1. Basic information about the village is not 1. Told supervisor to help ASHA for available. making village map. 2. Details and lists of immunization, TB, 2. Discussed with ANM and ASHA Leprosy, Diarrhea, Malaria patients are regarding Village Health plan and not available. also discussed with BPM. 3. Stethoscope not working properly.

4. Weighing machine for baby not working properly. District Rewa 1. Birth registration is mention but not 1. Suggested for updating of marriage marriage status updated registration 2. Names and services provided by ASHA, 2. Facilitated for preparation and displayed AWW and Sahayika are not available. the list of village health committee. 3. Details of midday meal scheme group is 3. Facilitated for preparation of midday meal not available group scheme list

4. List not available of village health committee. District Sehore 1. ASHA is aware about her duties but no 1. Provided guidance to prepare the Village plan prepared. health plan and advised to display the 2. CMHO, DPM DC's contact numbers is same.

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not available. 2. Provided guidance to prepare the Area 3. List of temporary methods of family Map. planning is not displayed. 3. Contact information of DC, CMHO, DPM, 4. Register for village health committee BMO, CDPO, Janani express provided. meetings not updated. 4. Advised to demand Weighing machine for baby.

5. Details of Self Help Group, Mothers Help Committee provided.

6. Advised to prepare the information of health services provided by ANM & MPW and their visits display in GAKs. District Sagar 1. Basic information about the village is 1. Suggested to ASHA to get the map and available with the ASHA but not updated. other demographic information ASAP. 2. Details of Self Help Group, Mothers Help 2. Suggested to ASHA to make village health Committee is not available. plan in supervision of ANM. 3. Suggested to maintain the records in the prescribed format. District Sidhi 1. Birth, Death & Marriage registration 1. ANM will assist to ASHA regarding details not available. preparing of Village Map and to collect 2. CMHO, DPM DC's contact numbers is information of population. not available. 2. GAK is recently shifted to ASHA's 3. IFA tablets – small not available house and within 7 days all protocol will maintain. District Tikamgarh 1. Only population is available with ASHA 1. Suggested to ASHA and AWW to and AWW. prepare the Village MAP on chart sheet. 2. AHSA is a member of Self Help Group 2. Suggested ASHA, ANM and MPW to but no information about SHG displayed. display the Self Help Group information at 3. Hub cutter Available but not kept in GAK. GAKs. 3. Instruct AHSA to prepare lists of 4. Details and lists of TB, Leprosy, immunization, TB, Leprosy, Diarrhoea, Malaria patients not available. Diarrhoea, Malaria patients. 4. Informed store keeper of Niwari CHC to provide ORS and other medicine to each ASHA during ASHA monthly meeting at Block level. 5. Instruct AHSA to prepare the fund Received and Expenses detail and place it at GAKs 6. Suggest ASHA to purchase the Box, torch, Almirah, water tank from VHSC united fund.

13 Case Studies

1. Sansari Bai, Rajnagar Village,

Sansari Bai, 25 years a resident of Rajnagar village in Chhatarpur district visited Gram Arogya Kendra with her 2 years old daughter. Her daughter was suffering from fever and she had not been eating well. She consulted ASHA at the GAK for this. ASHA examined the baby and found that the baby was having fever which came with chills. She gave the mother Fever tablets (Paracetamol) and informed ANM about the case. Next day on VHND, the ANM made slides for malaria test and she gave the baby anti-malarial tablets (Chloroquine). Her blood test was reported negative for malaria parasite after two days but fever was not coming now. Sansari Bai, followed the instructions and completed the course of malaria tablets.

She quoted to the district supervisory team that “Availability of medicines at Gram Arogya Kendra and ASHAs response saved her from going to a PHC which was 15 kilometers from her house and possible consequences of fever”.

2. Kusumwati, Khairi village, Chatarpur District

Kusumwati, 22 years was pregnant for second time. Her first baby, a girl was only 13 months old. She was told by village ASHA to come to gram Arogya Kendra for counselling and checkup. ASHA found that she was very weak and pale looking. ASHA counselled her for better nutrition and provided her Iron and Folic acid tablets. She was then followed up for ANC checkups on VHNDs by ANM along with ASHA. After continuous follow up, counselling, 3 ANC checkups and IFA consumption her hemoglobin remained 8 gm % during 7th month of pregnancy. She was then referred to the CHC for IV Iron sucrose therapy to improve her Hemoglobin levels before delivery.

At CHC she received three IV Iron sucrose infusions before her delivery and by the time she was full term, her hemoglobin had crossed 9.5 gm %. She finally had a normal delivery. As she was also counselled for postpartum family planning by the ASHA and ANM earlier she adopted PPIUCD.

ORS and Zinc Distribution at GAK

14 3. Sunita , Todha Gautamia village,

At Sagar district , Sunita, a 25 year old lady, got benefitted from the Gram Arogya Kendra. Her 3 year old son was having diarrohea and fever, for which she visited the GAK in Todha Gautamia village. The ASHA in that village provided her with ORS packet and Zinc tablets. The ASHA also demonstrated how to make ORS solution and how to give it to the boy. ASHA also gave her co-trimoxazole tablets as the boy was having fever also suspecting signs of some infection. Son of Sunita was fine after 3 days and Sunita was thankful to the ASHA of the village and government to have set up gram Arogya Kendra in her village.

Sunita was approached by supportive supervision team and she mentioned – “if these medicines were not available at the village GAK, she would have gone to see the private doctor to nearby village which would have costed her at least Rs. 200-300”.

15 Challenges

The exercise for strengthening of Gram Arogya Kendras has had certain limitations and challenges in terms of implementation as well as monitoring and supportive supervision done by the TAST teams.

1. At the start of inception of the program, it was mandated by the state to conduct supportive supervision based on the state developed checklist, which in itself has its limitations. The checklist doesn’t capture any data on service delivery and utilization, quality of services and any points which could capture information about further actions taken at sector, block, district or state level. 2. The number of Gram Arogya Kendra allotted are about 5000 for 16 districts. Keeping this in mind initially the visits were done by all the technical officers and DPCs posted at the districts, but gradually the task was shifted to only TO – health, which reduced the number of villages supported every month. This lead to a very little possibility of doing follow up visit at each of the center, which further culminated into limiting the data capturing only once from each center. 3. Since the amount of data received was very huge an online data entry tool was developed for the district teams, but it has remained a challenge to receive the qualitative information from this tool.

16 Conclusion

The Gram Arogya Kendra is a unique concept to promote village based health and nutrition activities, and for involving the community in their own health. By co-locating the AWC and GAK, all women and child-related services are made available in one place, and the community can more easily understand the links between health and its determinants like nutrition, water and sanitation. It is also in line with the 12th Plan priorities for system strengthening through decentralization, community involvement, and by improving interdepartmental co-ordination.

The support provided by the MPTAST has been instrumental in establishment of these centers in the supported districts. During the early phase of planning, recruitment of ASHAs in the villages where it was not present, mobilization of guidelines from district to the level of each sector medical officer, ANM and ASHA as well as printing and display of GAK related IEC material all was coordinated by the district teams. Further, mobilization of essential instruments, drugs and consumables was catalyzed by the district teams. Amongst all the unstructured and regular support provided to the district, the structured efforts started from the month of April onwards, which essentially have improved the functional status of the Gram Arogya Kendras. The major changes have been brought about in improving the functionality of VHSCs, availability of essential equipments like BP machine, Stethoscope, Thermometers, Uristics for testing glucose and albumin in urine, Malaria testing kits, medicines like albendazole, cotrimoxazole and family planning material.

These changes have been further translated into better service delivery by hands on trainings to AHSAs and ANMs. Further a regular follow up with the supportive supervision cadre of the GAKs which includes Block Community Mobiliser, Sector Supervisors and Sector Medical Officers.

At this point of time, the efforts are still continued to further keep improving the service availability, access and quality of services.

17 Annexure 1 Checklist for GAK assessment

SN Parameter 1 (yes) or 0 (No) Infrastructure & Basic amenities

1 Basic information about the village is available (Village map, area, population)

2 Village health plan is available

3 Contact information of DC, CMHO, DPM, BMO, CDPO, Janani express etc is available

4 Birth, Death & Marriage registration details available

5 Details of Self Help Group, Mothers Help Committee available

6 Details of mid day meal scheme group

7 Information about married & target couples, pregnant women, newborns, under five children, malnourished children, children registered in AWC available

8 Details and lists of immunization, TB, Leprosy, Diarrhea, Malaria patients available

9 List of temporary methods of family planning

10 Details of the information of health services provided by ANM & MPW and their visits available?

11 Names and services provided by ASHA, AWW and Sahayika are available

12 Information about the village health committee available

13 The VHC has details of the information about the funds received from health department, women & child development department and its expenditure

Instruments/Furniture availability

14 Chair

15 Table

16 Bench

17 ANC table

18 Foot step/stool for ANC table

19 Weighing machine for baby

20 Infantometer for newborn

21 Weight machine for children

22 Weight machine for adults

23 Haemoglobinometer

24 Stethoscope

25 Curtains

18 26 Fetu scope

27 Spirit lamp

28 Functional BP instrument

29 Hub cutter

30 Thermometer

31 Test tubes

32 Slides

33 Torch

34 Almirah

35 Box

36 Water tank

37 Glass

Availability of medicines & consumables:

38 All vaccines with diluents

39 ORS

40 IFA tablets - small & large

41 Cotrimoxazole tablets

42 Gention violet

43 Zinc sulphate dispersible tablets

44 Paracetamol tablet (500 mg)

45 Methyl ergomentrine tablets

46 Albendazole tablets (400 mg)

47 Dicyclomine tablets (10 mg)

48 Povidon Iodine ointment

49 Cotton bandage

50 Absorbant cotton

Deetails of additional information

51 Village health register

52 Death related information

53 Register for village health committee meetings

54 Register for other activities being done at the Gram Arogya Kendra

Details of information displayed at the GAK

55 Sign board for AWC & GAK

56 Notice board for displaying information outside the center

57 Description of village health plan displayed outside

Total Score (Out of 57) 0

Grade A (above 80%)= Green, B (61-80 %)= Yellow, C(<61%)= Red

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